Low TSH, elevated free T4 (dont check Total T4). 95% will have low TSH/high T4. 5% will have high T3 only. T3 is the more active form and can sometimes tell severity by the level of T3. T3 is the better test to check than T4 in the acute setting (USC Rounds, 2017).

ED Initial Treatment: Likely just HR control – control with propranolol (twice daily, inhibits peripheral conversion as well) vs atenolol (only once a day treatment). Make sure elevated HR is mild, no underlying illness (infection) and needs good followup to start thionamides and outpatient workup.

Thyroid Storm

Generally patient with hx/o hyperthyroidism with high fever and altered mental status.

CNS Abnormalities: can be as little as decreased concentration, though usually the hallmark is some marked confusion/psychosis. Any delirious/psychotic patient with fever/tachycardia, consider TS. Example of patient thinking their Jesus. Behavioral Health patient with either fever or elevated HR – check TSH.

CHF findings: high volume output CHF (HR too high to pump adequate blood out of heart) – can tolerate fluids, though if in severe CHF, be careful with them. Also listen for murmur or friction rub. Do not use diuretics.

Atrial Fibrillation: stick with Beta Blockers. Afib usually converts once HR decreases and TS is more controlled. Stay away from CCBs or digoxin.

Exogenous Thyroid Overdose: Only need to beta-block and give decadron for peripheral conversion. Hold off on thionamide/iodine since the thyroid still is functioning fine since it the medication is causing the problem.

Q1.What medication do you absolutely do not NOT want to start first on someone you are suspecting thyroid storm?

A1. Iodine containing medication (needs to be given 1-2 hrs after thionamides).

Q2. Patient presents with thyroid storm and need to stop hormone production, but patient has a severe iodine allergy listed. What other medication can you give as a substitute after giving a thionamide?

A2. Lithium. Put amiodarone as one of the choices as well (amiodarone causing increased hormone levels).

Q3. Which of the following is not in the criteria for thyroid storm by Burch and Wartofsky?